Silent Sinus Syndrome Presenting after a Roller Coaster Ride: A Case Report Eric L. Singman, M.D., Ph.D.1 Noelle S. Matta, C.O., C.R.C., C.O.T.2 David I. Silbert, M.D., F.A.A.P.2
ABSTRACT This is a case presentation of a 39-year-old male who presents with silent sinus syndrome. He was initially diagnosed by a neuroophthalmologist, and at first, the patient’s otolaryngologist disagreed. The patient had a significant reduction in his symptoms with surgical and orthoptic intervention.
INTRODUCTION A 39-year-old man presented to our practice in December 2004 with a two-month history of binocular vertical diplopia in upgaze and left gaze. He reported that this symptom began immediately after riding a roller coaster. He reported neither pain nor dizziness but felt the left eye “did not look right” and seemed to be sunken with the eyelid open wider. His medical history is significant for allergic rhinitis. His reFrom 1Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, and 2Family Eye Group, Lancaster, Pennsylvania. Requests for reprints should be addressed to: Noelle S. Matta, C.O., C.R.C., C.O.T., Family Eye Group, Vision Research Department, 2110 Harrisburg Pike, Suite 215, Lancaster PA 17601.
view of systems was otherwise negative. His driver’s license photo did not suggest an abnormal head posture. EXAMINATION On examination, the patient’s vertical fusion amplitudes were 0.5Δ. Sensorimotor showed an incomitant right hypertropia (Table). His near stereoacuity was 20’ arc. The eye movements were otherwise intact and there was no torsional component to the strabismus. His Hertels were: right eye 18 mm and left eye 16 mm. His marginal light reflex distance from the upper eyelid to the corneal light reflex (MRD1) was 3 mm on the right eye and 5 mm on the left eye. The patient did not maintain an abnormal head posture, nor was one seen when reviewing his driver’s license
© 2014 Board of Regents of the University of Wisconsin System, American Orthoptic Journal, Volume 64, 2014, ISSN 0065-955X, E-ISSN 1553-4448
American Orthoptic Journal
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SILENT SINUS SYNDROME
TABLE 1 INITIAL SENSORIMOTOR EXAM Ortho
RHT 4, XT 3 RH 2 Ortho
RHT 3
Head tilt right RHT 1, head tilt left RHT 2. RHT— right hypertropia, XT—exotropia, RH—right hyperphoria, ortho—orthophoric.
photo. The patient’s pupils reacted normally and his slit-lamp and fundoscopic examinations proved to be normal as well. TREATMENT The patient was offered a computed tomography (CT) scan and the result showed significant and asymmetric sinus disease (Figure). We believed there was in-bowing of the left maxillary sinus and referred the patient to an otolaryngologist for treatment of presumed Silent Sinus Syndrome (SSS). The otolaryngologist disagreed with the diagnosis, but did agree with the need for sinus surgery. The patient was then seen by an oculoplastics specialist who did agree with the diagnosis of SSS and the need for sinus surgery and recognized that there might be a need for orbital reconstruction after the sinus surgery. The patient underwent successful endoscopic sinus surgery (septoplasy with anterior and posterior ethmoidectomy, maxillary anstrostomy, trimming of left middle turbinate, CoblationTM (ArthroCare Corp.), and outfracture of left inferior turbinate). A few months later, the patient also underwent orbital surgery with an oculoplastic surgeon (placement of implant in the floor of the left orbit). The diplopia improved, but the patient was still symptomatic in up-gaze and left head tilt from a right hypertropia. He was provided glasses with base-down prism, which he wore as needed over the next few years. At his final visit (4 years after the onset of his symptoms), his alignment was orthophoric in all directions of gaze and the Hertels were 18 mm in the
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right eye and 19 mm in the left eye. He still maintained an excellent stereoacuity of 20’ arc and had no objective torsion. He was no longer dependent upon the prism glasses. SILENT SINUS SYNDROME Silent Sinus Syndrome is a condition in which spontaneous enophthalmos and hypoglobus develops secondary to an alteration of the normal orbital architecture,1 specifically a collapse (i.e., atelectasis) of the orbital floor into the maxillary sinus.2, 3 This collapse is believed to be related to negative air pressure that develops in the maxillary sinus in the setting of chronic sinusitis.4 Associated findings may include facial asymmetry and sinus pain.2, 5 As in our case, vertical diplopia has been reported to be the presenting symptom.6 In addition, patients can present with a variety of orbital findings.7 In rare instances, the disease is bilateral.8 The otolaryngologic literature suggests that the first step in therapy is endoscopic sinus surgery aimed at permitting normal aeration of the maxillary sinus. Thereafter, different approaches have been advocated for reconstruction of normal globe position. Most reports published suggest that therapy may require two steps, i.e., first sinus surgery and then secondary orbital reconstruction, as in our case. However, Sivasubramanian et al. have reported that in many cases, normalizing the pressure in the orbits will ultimately provide sufficient improvement and patients should be given more time to reach a stable state postoperatively.9 Mavrikakis et al. reported that normal globe position and function could be restored in cases where re-aeration alone was insufficient by injecting hyaluronic gel into the orbit, under the globe.10 Furthermore, Sesenna et al. suggests that a single trip to the operating room where a patient is offered combined surgery to correct both maxillary sinus aeration and orbital architecture has particular benefits.11
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SINGMAN
FIGURE: The CT frame on the left shows the preoperative sinus disease and atelectasis of the right maxillary sinus. The frame on the right shows postoperative improvement of sinus aeration, but persistent asymmetric narrowing of the right maxillary antrum.
CONCLUSION To our knowledge, our patient represents the first reported case of Silent Sinus Syndrome to occur following a ride on a roller coaster. Although roller coaster rides have been reported to induce barotrauma, particularly to the auditory pathways,12 we do not know whether it was etiologic in our patient’s situation. REFERENCES 1. Numa WA, Desai U, Gold DR, et al.: Silent sinus syndrome: A case presentation and comprehensive review of all 84 reported cases. Ann Otol Rhinol Laryngol 2005; 114:688-694. 2. Illner A, Davidson HC, Harnsberger HR, et al.: The silent sinus syndrome: Clinical and radiographic findings. AJR Am J Roentgenol 2002; 178:503-506. 3. Rose GE, Sandy C, Hallberg L, Moseley I: Clinical and radiologic characteristics of the imploding antrum, or “silent sinus” syndrome. Ophthalmology 2003;110:811-818. 4. Kass ES, Salman S, Montgomery WW: Manometric study of complete ostial occlusion in chronic maxillary atelectasis. Laryngoscope 1996; 106:1255-1258. 5. Wan MK, Francis IC, Carter PR, et al.: The spectrum of presentation of silent sinus syndrome. J Neuroophthalmol 2000; 20:207-212.
American Orthoptic Journal
6. Saffra N, Rakhamimov A, Saint- Louis LA, Wolintz RJ: Acute diplopia as the presenting sign of silent sinus syndrome. Ophthal Plast Reconstr Surg 2013; 29:e130-131. 7. Wise SK, Wojno TH, DelGaudio JM: Silent sinus syndrome: Lack of orbital findings in early presentation. Am J Rhinol 2007; 21:489-494. 8. Suh JD, Ramakrishnan V, Lee JY, Chiu AG: Bilateral silent sinus syndrome. Ear Nose Throat J 2012; 91:e19-21. 9. Sivasubramaniam R, Sacks R, Thornton M: Silent sinus syndrome: Dynamic changes in the position of the orbital floor after restoration of normal sinus pressure. J Laryngol Otol 2011; 125:1239-1243. 10. Mavrikakis I, Detorakis ET, Yiotakis I, Kandiloros D: Nonsurgical management of silent sinus syndrome with hyaluronic acid gel. Ophthal Plast Reconstr Surg 2012; 28:e6-7. 11. Sesenna E, Oretti G, Anghinoni ML, Ferri A: Simultaneous management of the enophthalmos and sinus pathology in silent sinus syndrome: A report of three cases. J Craniomaxillofac Surg 2010; 38:469- 472. doi: 10.1016 / j.jcms.2009.12.003. E-pub 2010 Jan 21. 12. Al-Khudari S, Loochtan M, Yaremchuk K: Roller coaster-induced barotrauma. Laryngoscope 2011; 121:501-502. doi: 10.1002/lary.21424. E-pub 2010 Dec 9.
Key words: silent sinus syndrome, diplopia, sensorimotor exam, roller coaster
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ABSTRACT This is a case presentation of a 39-year-old male who presents with silent sinus syndrome. He was initially diagnosed by a neuroophthalmologist, and at first, the patient’s otolaryngologist disagreed. The patient had a significant reduction in his symptoms with surgical and orthoptic intervention.
INTRODUCTION A 39-year-old man presented to our practice in December 2004 with a two-month history of binocular vertical diplopia in upgaze and left gaze. He reported that this symptom began immediately after riding a roller coaster. He reported neither pain nor dizziness but felt the left eye “did not look right” and seemed to be sunken with the eyelid open wider. His medical history is significant for allergic rhinitis. His reFrom 1Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, and 2Family Eye Group, Lancaster, Pennsylvania. Requests for reprints should be addressed to: Noelle S. Matta, C.O., C.R.C., C.O.T., Family Eye Group, Vision Research Department, 2110 Harrisburg Pike, Suite 215, Lancaster PA 17601.
view of systems was otherwise negative. His driver’s license photo did not suggest an abnormal head posture. EXAMINATION On examination, the patient’s vertical fusion amplitudes were 0.5Δ. Sensorimotor showed an incomitant right hypertropia (Table). His near stereoacuity was 20’ arc. The eye movements were otherwise intact and there was no torsional component to the strabismus. His Hertels were: right eye 18 mm and left eye 16 mm. His marginal light reflex distance from the upper eyelid to the corneal light reflex (MRD1) was 3 mm on the right eye and 5 mm on the left eye. The patient did not maintain an abnormal head posture, nor was one seen when reviewing his driver’s license
© 2014 Board of Regents of the University of Wisconsin System, American Orthoptic Journal, Volume 64, 2014, ISSN 0065-955X, E-ISSN 1553-4448
American Orthoptic Journal
123
SILENT SINUS SYNDROME
TABLE 1 INITIAL SENSORIMOTOR EXAM Ortho
RHT 4, XT 3 RH 2 Ortho
RHT 3
Head tilt right RHT 1, head tilt left RHT 2. RHT— right hypertropia, XT—exotropia, RH—right hyperphoria, ortho—orthophoric.
photo. The patient’s pupils reacted normally and his slit-lamp and fundoscopic examinations proved to be normal as well. TREATMENT The patient was offered a computed tomography (CT) scan and the result showed significant and asymmetric sinus disease (Figure). We believed there was in-bowing of the left maxillary sinus and referred the patient to an otolaryngologist for treatment of presumed Silent Sinus Syndrome (SSS). The otolaryngologist disagreed with the diagnosis, but did agree with the need for sinus surgery. The patient was then seen by an oculoplastics specialist who did agree with the diagnosis of SSS and the need for sinus surgery and recognized that there might be a need for orbital reconstruction after the sinus surgery. The patient underwent successful endoscopic sinus surgery (septoplasy with anterior and posterior ethmoidectomy, maxillary anstrostomy, trimming of left middle turbinate, CoblationTM (ArthroCare Corp.), and outfracture of left inferior turbinate). A few months later, the patient also underwent orbital surgery with an oculoplastic surgeon (placement of implant in the floor of the left orbit). The diplopia improved, but the patient was still symptomatic in up-gaze and left head tilt from a right hypertropia. He was provided glasses with base-down prism, which he wore as needed over the next few years. At his final visit (4 years after the onset of his symptoms), his alignment was orthophoric in all directions of gaze and the Hertels were 18 mm in the
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right eye and 19 mm in the left eye. He still maintained an excellent stereoacuity of 20’ arc and had no objective torsion. He was no longer dependent upon the prism glasses. SILENT SINUS SYNDROME Silent Sinus Syndrome is a condition in which spontaneous enophthalmos and hypoglobus develops secondary to an alteration of the normal orbital architecture,1 specifically a collapse (i.e., atelectasis) of the orbital floor into the maxillary sinus.2, 3 This collapse is believed to be related to negative air pressure that develops in the maxillary sinus in the setting of chronic sinusitis.4 Associated findings may include facial asymmetry and sinus pain.2, 5 As in our case, vertical diplopia has been reported to be the presenting symptom.6 In addition, patients can present with a variety of orbital findings.7 In rare instances, the disease is bilateral.8 The otolaryngologic literature suggests that the first step in therapy is endoscopic sinus surgery aimed at permitting normal aeration of the maxillary sinus. Thereafter, different approaches have been advocated for reconstruction of normal globe position. Most reports published suggest that therapy may require two steps, i.e., first sinus surgery and then secondary orbital reconstruction, as in our case. However, Sivasubramanian et al. have reported that in many cases, normalizing the pressure in the orbits will ultimately provide sufficient improvement and patients should be given more time to reach a stable state postoperatively.9 Mavrikakis et al. reported that normal globe position and function could be restored in cases where re-aeration alone was insufficient by injecting hyaluronic gel into the orbit, under the globe.10 Furthermore, Sesenna et al. suggests that a single trip to the operating room where a patient is offered combined surgery to correct both maxillary sinus aeration and orbital architecture has particular benefits.11
Volume 64, 2014
SINGMAN
FIGURE: The CT frame on the left shows the preoperative sinus disease and atelectasis of the right maxillary sinus. The frame on the right shows postoperative improvement of sinus aeration, but persistent asymmetric narrowing of the right maxillary antrum.
CONCLUSION To our knowledge, our patient represents the first reported case of Silent Sinus Syndrome to occur following a ride on a roller coaster. Although roller coaster rides have been reported to induce barotrauma, particularly to the auditory pathways,12 we do not know whether it was etiologic in our patient’s situation. REFERENCES 1. Numa WA, Desai U, Gold DR, et al.: Silent sinus syndrome: A case presentation and comprehensive review of all 84 reported cases. Ann Otol Rhinol Laryngol 2005; 114:688-694. 2. Illner A, Davidson HC, Harnsberger HR, et al.: The silent sinus syndrome: Clinical and radiographic findings. AJR Am J Roentgenol 2002; 178:503-506. 3. Rose GE, Sandy C, Hallberg L, Moseley I: Clinical and radiologic characteristics of the imploding antrum, or “silent sinus” syndrome. Ophthalmology 2003;110:811-818. 4. Kass ES, Salman S, Montgomery WW: Manometric study of complete ostial occlusion in chronic maxillary atelectasis. Laryngoscope 1996; 106:1255-1258. 5. Wan MK, Francis IC, Carter PR, et al.: The spectrum of presentation of silent sinus syndrome. J Neuroophthalmol 2000; 20:207-212.
American Orthoptic Journal
6. Saffra N, Rakhamimov A, Saint- Louis LA, Wolintz RJ: Acute diplopia as the presenting sign of silent sinus syndrome. Ophthal Plast Reconstr Surg 2013; 29:e130-131. 7. Wise SK, Wojno TH, DelGaudio JM: Silent sinus syndrome: Lack of orbital findings in early presentation. Am J Rhinol 2007; 21:489-494. 8. Suh JD, Ramakrishnan V, Lee JY, Chiu AG: Bilateral silent sinus syndrome. Ear Nose Throat J 2012; 91:e19-21. 9. Sivasubramaniam R, Sacks R, Thornton M: Silent sinus syndrome: Dynamic changes in the position of the orbital floor after restoration of normal sinus pressure. J Laryngol Otol 2011; 125:1239-1243. 10. Mavrikakis I, Detorakis ET, Yiotakis I, Kandiloros D: Nonsurgical management of silent sinus syndrome with hyaluronic acid gel. Ophthal Plast Reconstr Surg 2012; 28:e6-7. 11. Sesenna E, Oretti G, Anghinoni ML, Ferri A: Simultaneous management of the enophthalmos and sinus pathology in silent sinus syndrome: A report of three cases. J Craniomaxillofac Surg 2010; 38:469- 472. doi: 10.1016 / j.jcms.2009.12.003. E-pub 2010 Jan 21. 12. Al-Khudari S, Loochtan M, Yaremchuk K: Roller coaster-induced barotrauma. Laryngoscope 2011; 121:501-502. doi: 10.1002/lary.21424. E-pub 2010 Dec 9.
Key words: silent sinus syndrome, diplopia, sensorimotor exam, roller coaster
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